The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now. The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
• An independent and robust Public Health England;
• A coherent career and training structure for public health professionals;
• Protection of terms and conditions of staff;
• Directors of public health reporting to chief executives of councils,
• Clarity in the size and applications of the ring fenced budget and
• Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage. However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began. NHS planning has historically relied on regulations and guidance, not legislation. This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog. It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.

As the Health and Social Care Bill makes its journey through the Committee Stage at the House of Lords, FPH continues to actively engage with members, key stakeholders, parliamentarians, as well as through its representation on strategic working groups and supported by its wider media work.

Committed to ensuring the Bill will provide the structures and safeguards necessary to protect and improve the health and wellbeing of the people of England, FPH is working hard to ensure a strong and viable public health workforce is maintained and strengthened for the future; and a rigorous framework for the statutory registration and regulation of all public health specialists to protect the public is established.

As we continue to press hard for amendments to the Bill, at the forefront of our minds the risks to the public posed by the Bill – E.Coli, SARS, pandemic flu, Buncefield, heatwaves, flooding, immunisation and screening – loom large. To meet this challenge, with Lord Patel taking a lead on FPH’s amendments, we maintain a focus on statutory regulation; the role, qualifications and accountability of directors of public health; the organisation independent of Public Health England; public health expertise in the new NHS Commissioning Board; employment conditions for public health professionals at parity with the NHS.

Over the past few months, FPH has developed and implemented a firm lobbying strategy. We have written to all MPs and peers taking part in the Health Bill readings in both the House of Commons and Lords, setting out a clear case for our amendments to the Bill. We have the support of a broad range of peers from across all political parties – and have regular meetings with peers to discuss the possible impacts of the Bill in the context of public health.

We are also working with other health and public health organisations through our chairing of the PHMCC task group, and actively engaging with local government colleagues – including producing a joint statement with the Local Government Group. We also have representatives on key strategic groups, including the Public Health England Group (feeding into the development of the PHE Outcomes Framework) and the Workforce Advisory Group and have taken an active involvement in the NHS Future Forum Process with a submission recently sent in for the Second stage. FPH also maintains close working relationships with other faculties, Royal Colleges and stakeholders to share information and horizon-scan.

Informing our position, three member surveys have been conducted to ensure that we are engaging our members in a full and meaningful dialogue. At present we are in the process of analysing the results of our latest survey of members’ views of the Health Bill, with a full analysis to follow shortly. In addition, FPH works closely with its Local Board Members to encourage their active engagement with local MPs and relevant stakeholders.

Our lobbying work around the Bill has been supported by our wider media work, delivering news articles including a recent response to the Health Select Committee 12th Report on Public Health appearing in the Guardian (a copy at this link); and letter to the Times outlining our key concerns with the Bill. In turn our monthly bulletin continues to keep all of our 3,500 members abreast of the latest developments.

A perfect storm has been brewing over the summer about press invasions of privacy and corrupt police practices. But if the public and politicians are concerned about the threat to their privacy how much more should they be concerned about the threat to their health?

In its response to the public health white paper consultation, The Way Forward, the Department of Health says effectively: “Show us more evidence that regulation of public health professionals is required.” Was the Secretary of State not in the House on Wednesday 13 July? Or lurking in the corridors of power for the select committee interrogation of the Murdochs on 19 July? Has he not heard the pronouncements of the Prime Minister about the regulation of the press? Do these not offer any clues on the need for regulation of public health specialists? The story below is from the Health Service Journal in the autumn of 2016…

“In separate incidents around the country – the UK public health system has failed to stop major outbreaks of tuberculosis, E coli hemolytic uremic syndrome and salmonella. There have been high-profile deaths from the failure to immunize against measles. Major screening disasters have seen deaths of women from preventable cervical and breast cancers. Public concern has been heightened by further allegations that local health and wellbeing board strategies have failed to identify people at highest risk of coronary heart disease and so implement the most effective strategies for preventing death and disability. Public safety was compromised when the Government refused to take action to regulate all public health specialist practice. Local authorities handed public health duties to assistant directors in council services without formal and approved public health qualifications, to agreed national standards.

“The prime minister, under pressure from unprecedented public concern made the following statement yesterday: ‘Not the smallest freedom we cherish in this country is the freedom to be alive. People who were not fit and proper were allowed to undertake vital roles in securing public health safety, in setting priorities for local authorities to determine which life-saving services they should invest in and advise clinical commissioning groups where the best choices to save lives were to be made.

“‘I am determined that this government will take the following actions. One: action will be taken to get to the bottom of the specific revelations and allegations about incompetent management of infectious-disease outbreaks, poor surveillance of major public health problems and inadequate advice to health and wellbeing boards and clinical commissioners to determine where local government and health services should have spent their money. Two: action will be taken to learn wider lessons for the future of the public health profession in this country. And three: that there will be clarity – real clarity – about how all this has come to pass and the responsibilities we all have for the future.

“‘…We need action as well to learn the wider lessons for the future. In particular, we should look at how our public health services are regulated and make recommendations… Of course it is vital that our public health specialists are independent. But public health freedom does not mean that public health should be above the law. Yes, there is much excellent public health practice in Britain today. But I think it’s now clear to everyone that the way public health is regulated is not working. Let’s be honest, voluntary regulation has failed. In these cases it was, frankly, completely absent. Therefore we have to conclude that it is ineffective and lacking in rigour. There is a strong case for saying it is institutionally conflicted. As a result, it lacks public confidence. So I believe we need a new system entirely.

“‘For people watching this scandal unfold, there is something disturbing about what they see. Just think of those in whom they put their trust: the politicians to represent them and Public Health England and local authority public health to inform them and protect them. All of them have let them down.

“‘…I want a regulatory system that is statutory and ensures the safety of the public’s health that has proved itself beyond reproach… a political system that people feel is on their side… and public health practitioners that are, yes, independent and rigorous, that investigate and protect, …that hold those in power to account and occasionally – yes, even regularly – drive them mad, but, in the end, are an independent professional public health service that are also clean and trustworthy. That is what people want. That is what I want. And I will not rest until we get it.’

“The BBC’s political editor asked the question: ‘Prime minister, isn’t that what the Scally report recommended in 2010?'”

The NHS Futures Forum got it. The Government refused to accept its recommendation. The Way Forward document still asks for more evidence that public health needs statutory regulation across all its professionals. Public health is life-saving business. The public deserves to be protected. The professionals deserve protection from themselves. Their employers need protection through assurance of standards and regulation. What’s right for the press is right also for the public’s health.

Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners. Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost. Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are. Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base. But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery. This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

The public health white paper promises to ‘improve the health of the poorest fastest.’ Health Secretary Andrew Lansley has said that closing the health inequalities gap is a top priority, echoing the Marmot Review – ‘more must be done to tackle the causes of the causes of ill-health.’ To this end he has set up a cross-government committee on public health and has proposed a shift of responsibility for health improvement onto local government, along with a ‘ring-fenced’ public health budget. Joined-up at the top and bottom.

So far, so good. Many would agree that local government is the natural home for the public health and wellbeing agenda. It’s where the big local decisions about social determinants take place and where a properly coordinated approach could really pay off. Localism in action.

The flipside of course is that the Coalition’s Health Secretary, with one deft move, will be off-loading this most stubborn of health challenges. Despite massive investment by the previous government, the inequalities gap has continued to widen. In taking on this agenda, local authorities might find themselves accepting a poisoned chalice.

If that was apparent before the Chancellor’s spending review, how much more so it is now we know the breadth and extent of Osborne’s austerity drive. Massive cuts in benefits and public services, soaring unemployment, a deep-frozen NHS and the rise in VAT, all add up to millions more people in difficulty – a situation which, according to the Institute for Fiscal Studies, is bound the hit the poorest hardest.

We know that maternity problems, infant ill-health, low uptake of childhood immunisation, poor oral health, child and adolescent mental ill-health, accidents and violence, depression and suicide, cancer diagnosis and heart disease, and the debilitating dependency of old age are all strongly linked to social deprivation. We can surely expect a huge upsurge in demand on the NHS – at a time when services are already overstretched.

As ever, it will be the disadvantaged who will miss out. The health inequalities gap is bound to widen and no amount of shifting the public health deckchairs, as envisaged in the public health white paper, can stop it. Indeed the distraction and planning blight that comes with the wider NHS reorganisation laid out in the Health & Social Care Bill can only add to the barriers faced by disadvantaged people.

The Health Secretary no doubt sees all this, but is determined to push his changes through, despite a barrage of opposition from many quarters. His view is that, whilst things will be tough in the early years, there are green Elysian Fields beyond. In the meantime, we can help him to get it right by responding to the White Paper consultations and cajoling our MPs to amend the Bill as it goes through Parliament.

A key issue is the ring-fenced budget for public health, particularly for the health improvement element that will be passed to local authorities. We don’t yet know the size of the ring-fenced allocation at national level, although a figure of about £4billion has been bandied about. That sounds a big number – but by the time the many millions have been taken out to support the work that the Health Protection Agency is currently doing, and the National Treatment Agency for Substance Misuse, and national campaigns, and various other central initiatives, the amount distributed to local level will be much truncated.

And then that local pot gets divvied up between the Public Health England unit, public health support to GP consortia, prevention activity by GPs, immunisation, screening, drugs and alcohol, child health checks, health visiting, etc etc – the list goes on. So, what will be left to hand over to local authorities to tackle the health and wellbeing agenda? Not a lot, I suspect. Local authorities (and their Directors of Public Health) will be taking on a huge added responsibility with very little resource to throw at it. More for less indeed.

And those LAs struggling to improve their health outcomes because of challenging demographics could find themselves further disadvantaged by the Health Minister’s proposed ‘health premium’ scheme. The intention is to reward only those LAs who ‘make significant progress’ towards better outcomes, including reduced health inequalities. But those of us who have worked with multi-deprived populations know how difficult this can be, despite heroic efforts, without major demographic change. Although we’re told the health premium assessment would take deprivation into account, there’s every chance that yet again it would be the more disadvantaged populations who miss out on any extra funding. So much for improving the health of the poorest fastest. No, as bright ideas go, I can’t help thinking this isn’t one of them.

There’s plenty of Christmas cheer in the public health white paper. Warming words about the importance of protecting and improving health.

A bulging sackful of goodies – health improvement to be a statutory duty for local authorities; directors of public health (DsPH) to be embedded in local government where they truly belong; a new national public health service (Public Health England) to extend the kindly hand of the Department of Health to local level; a gift-wrapped ring-fenced budget for public health. Even a heavenly choir chanting about improving the health of the poorest fastest. It could all be straight out of Dickens.

But let’s not reach for the mulled claret and wassail too soon – there are a few reindeer in the room. For instance, the white paper says there will be ‘minimum constraints on how local government decides to fulfil its public health role and spend its new budget.’ So will DsPH have any real clout in the new set-up? Will they be on a par with chief officers reporting direct to the council CEO? What influence will they have over the public health budget? Just how ‘ring-fenced’ will it really be – and for how long? We’ll have to wait for further guidance next year – but it looks as though councils will have pretty free rein.

Then there’s the crucial issue of joined-upness. How effective will the linkage be between local government, GP commissioners, the local PHE health protection unit, and other stakeholders? We know the instrument will be the local Health and Wellbeing Board, using the Joint Strategic Needs Assessment as a blueprint – but how well will these boards work? We’ve had patchy experience with Local Strategic Partnerships. The whole new public health edifice will stand or fall on how robustly these boards are set up. Again the blueprint is forthcoming.

And no details yet on how local authorities will be rewarded on their achievement of health outcomes – or not, as the case may be. The public health outcomes framework is still being worked on, as is the reward system. But the metrics of public health are notoriously complex and shifting. Populations don’t stay still. Mortality-based outcomes are far too blunt and sluggish to be used for real-time monitoring and performance rating. Health behaviours such as smoking, drinking, diet and exercise are too much influenced by externalities. Even risk factor prevalence has its problems. It would take an Einstein to come up with a fair approach to dishing out the ‘health premium’ for good results.

The outcome of improving the health of the poorest fastest is a case in point. As the ex-DPH of a deprived inner-city borough I particularly worry about those areas struggling to reduce health inequalities. Even in times of plenty the gap remained stubbornly persistent – the better-off have always tended to improve their health faster than the have-nots. If anything, the government’s drastic cuts look set to hit the poorest hardest, with negative consequences for health. It would be cruelly unfair to penalise local authorities for failing to close their inequalities gap when the cards are so heavily stacked against them. That would surely be an act of Scrooge-like heartlessness in these hard times. Dickens would turn in his grave.

Uncertainty shrouds the future of public health. Or so it seems if the responses of the 1,160 Faculty of Public Health members, who took part in FPH’s survey on the NHS White Paper, are anything to go by.

But despite the many question marks around the proposed reorganisation, FPH’s specialist public health members still manage to be pretty damning. Nearly 40% of respondents doubted the White Paper would have a positive impact on population health. Furthermore, the majority (38.3%) believed that the proposed new structures would offer worse or much worse value for money. Many highlighted the fact that the healthcare public health strand of the specialty was simply ‘forgotten’, with 56.9% saying that public health as a whole wasn’t sufficiently covered.

There’s also drive and energy out there – public health teams are proud of their expertise and skills, and know their input is vital to the communities they work in around the country. The independent advocacy role of the director of public health was one area they were ready to defend. 98.3% thought that the DPH should be free to report objectively on the health impact of local policies. And 91.5% said the DPH should report independently on the population’s health.

It’s not all doom and gloom, however. Despite the fact that no-one has mentioned the plans to change the ‘Department of Health’ to ‘Department of Public Health’ for a while now, the public health workforce does seem quietly hopeful that the reorganisation will create a better and more efficient national public health service. The Coalition Government’s apparent commitment to public health hasn’t gone unnoticed.

Public health specialists are clearly keeping an open mind while waiting for the uncertainty to lift. But their hope, energy and loyalty should not be taken for granted. Nearly half (46.8%) of the respondents thought that the changes and uncertainty would mean fewer trainees applying to work in public health. If they are right, the future of public health – and the public’s health – is on very shaky grounds indeed.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.